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Medical Terminology > Exam 2 study guide > Flashcards

Exam 2 study guide Flashcards

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USMLE® Step 1 flashcards
0
Q

4 techniques used to obtain the primary objective data during the physical assessment

A
  • Inspection (visual examination)
  • Palpation (touch)
  • Percussion (tapping the body surface)
  • Direct auscultation (listening with the unaided ear)
  • Indirect auscultation (listening with the stethoscope)
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1
Q

Functional ability assessment

A
  • Important in discharge planning and home care
  • future rehabilitation needs are derived from initial and ongoing assessment
  • Joint commission requires for all patients
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2
Q

Subjective data

A

Info communicated to the nurse by the client, family or community

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3
Q

Objective data

A

Gathered through
physical assessment
laboratory
diagnostic tests

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4
Q

Primary data

A
  • subjective and objective info obtained from the client

- what the client says or what you observe

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5
Q

Secondary data

A

Obtained secondhand from a
medical record
another caregiver

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6
Q

Comprehensive assessment

A
  • provides holistic info about the clients overall health status
  • enables you to identify client problems and strengths
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7
Q

Focused assessment

A
  • performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected
  • Focuses on a particular topic, body part, or functional ability rather than on overall health status
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8
Q

closed question

A

yes, no, or short factual answers

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9
Q

Open-ended questions

A
  • Specify a topic to be explored
  • Are phrased broadly to encourage the patient to elaborate
  • Ask when you want to obtain subjective data
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10
Q

Biographical data

A
  • Unchanging info
  • ## Responses reflect mental status of patient and ability to communicate
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11
Q

Past health history

A
  • Includes childhood diseases, immunizations, previous hospitalizations, and previous surgeries
  • Help guide your assessment
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12
Q

Diagnosis step of the nursing process

A
  • A clinical judgment about individual, family, community responses to actual or potential health problems/life processes
  • Provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable for
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13
Q

Nursing diagnosis

A

statement of client health status that nurses can identify, prevent, or treat independently

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14
Q

Medical diagnosis

A
  • Describes a disease, injury, or illness
  • Purpose to identify a pathology so that appropriate treatment can be given
  • more narrowly focused then a nursing diagnosis
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15
Q

Collaborative problem

A

Certain physiological complications ( of disease, medical treatments, or diagnostic studies) that nurses monitor to detect onset or changes in status

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16
Q

NANDA was established in

A

1982

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17
Q

NANDA-1 was established in

A

2002

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18
Q

Cluster cues

A
  • Group of cues that are related to each other in some way
  • May suggest a health problem
  • To help ensure accuracy you should always derive a nursing diagnosis from data clusters rather than from a single cue
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19
Q

Prioritizing problems

A
  • Places the problems in order of importance

- Does not mean you must resolve one problem before another

20
Q

The 3 components of the PES system

A

Problem
Etiology
Symptoms

21
Q

P (Problem)

A

The nursing diagnosis label: a concise term or phrase that represents a pattern of related cues

22
Q

E (Etiology)

A

Related to (r/t) phrase of etiology: related cause or contributor to the problem

23
Q

S (Symptoms)

A

Defining characteristics phase: symptoms that the nurse identified in the assessment

24
Q

Actual nursing diagnosis

A
  • Describes human responses to health conditions/life processes that exist in an individual family or group, or community
  • Supported by defining characteristics and related factors
25
Q

Risk nursing diagnosis

A
  • A clinical judgment about human experiences/responses to health conditions/life processes that have a high probability of developing in a vulnerable individual, family, group, or community
  • Supported by risk factors
26
Q

Health-promotion nursing diagnosis

A
  • A clinical judgment about a person’s family’s, groups’s, or community’s motivation and desire to increase well being and actual human health potential as expressed in the readiness to enhance specific health behaviors, which can be used in any health state
27
Q

Related to (r/t) phase

A
  • second part of the nursing diagnosis
  • factors that appear to show some type of pattern relationship with the nursing diagnosis
  • Enables the nurse to plan nursing interventions and refer for diagnostic procedures, medical treatments, pharmaceutical interventions, and others that will assist the client/family in accomplishing goals and return to state of optimum health
28
Q

Defining characteristics phase

A
  • 3rd part of the 3 part diagnostic system
  • consists of signs and symptoms that have been gathered during the assessment phase
  • The phrase as evidence by (aeb) may be used to connect the etiology
    (r/t) with the defining characteristics
29
Q

6 standards of practice

A 
Assessment
Diagnosis
Outcome identification
Planning
Implementation
- Coordination of care
- Health teaching and health promotion
- Consultation
- Prescriptive authority and treatment
Evaluation
30
Q

Function of the scope of practice

A 
who
what
where
when 
why
how
31
Q

Advanced practice role

A 
Masters or doctoral degree
Umbrella term for
- Certified registered nurse anesthetist (CRNA)
- Certified nurse midwife (CNM)
- Clinical nurse specialist (CNS)
- Nurse practitioner (NP, APRN, DNP)
Build on RN practice with 
- Greater breadth and depth of knowledge
- Greater synthesis of data
- Increased complexity of skills and interventions
- Significant role autonomy
32
Q

10 standards of professional performance

A

-Ethics
-Education
-Evidence based practice and research
-Quality of practice
-Communication
-Leadership
-Collaboration
-Professional practice evaluation
-Resource utilization
-Environmental health
-

33
Q

Colorado Nurse Practice Act

A 
-Revised 1 July 2010
Sets the requirements for:
- professional, advanced practice, and practical nurse licensure
- temp and volunteer licensure
Grounds for discipline
34
Q

Code of Ethics

Provision 1

A
  • Respect for human dignity
  • Relationships to patients
  • The nature of health problems
  • The right to self determination
  • Relationships with colleagues and others
35
Q

Code of Ethics

Provision 2

A
  • Primacy of the patients interests
  • Conflict of interest for nurses
  • Collaboration
  • Professional boundaries
36
Q

Code of Ethics

Provision 3

A
  • Privacy
  • Confidentiality
  • Protection of participants in research
  • Standards and review mechanisms
  • Acting on questionable practice
37
Q

Code of Ethics

Provision 4

A
  • Acceptance of accountability and responsibility
  • Accountability for nursing judgment and action
  • Responsibility form nursing judgment and action
  • Safe delegation of nursing activities
38
Q

Code of Ethics

Provision 5

A
  • Moral self-respect
  • Professional growth and maintenance of competence
  • Wholeness of character
  • Preservation of integrity
39
Q

Code of Ethics

Provision 6

A
  • Influence of the environment on moral virtues and values
  • Influence of the environment on ethical obligations
  • Responsibility for the healthcare environment
40
Q

Code of Ethics

Provision 7

A
  • Advancing the profession through active involvement in nursing and in healthcare policy
  • Advancing the profession by developing, maintaining, and implementing professional standards in clinical, administration, and educational practice
  • Advancing the profession through knowledge development, dissemination, and application to practice
41
Q

Code of Ethics

Provision 8

A
  • Health needs and concerns

- Responsibilities to the public

42
Q

Code of Ethics

Provision 9

A
  • Assertion of values
  • The profession carries out its collective responsibility through professional associations
  • Intra-professional integrity
  • Social reform
43
Q

Components of a goal statement

A
  • Subject
  • Action
  • Performance criteria
  • Target time
  • Special conditions
44
Q

NOC outcomes

A
  • Outcome label
  • Indicators
  • Measurement scale
45
Q

Individualized Nursing Care Plan

A
  • Used to address nursing diagnosis unique to a particular client
46
Q

Special Discharge or Teaching care plan

A
  • May use standardized plan or include as teaching in a nursing diagnosis care plan
47
Q

Computerized Care Plan

A
  • Enter diagnosis or desired outcome
  • Computer generates list of suggested interventions
  • Choose appropriate interventions
  • Individualize by typing in own interventions as needed

Medical Terminology (19 decks)

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